Disclosure in Anonymous Donor Egg IVF

By: Laurence C. Udoff, MD, FACOG

I am often asked what part of my job I find the most gratifying. Though in general, I consider it a privilege to play a role in the care of all of my patients, working with donor egg IVF patients offers special rewards for both the patient and the caregiver. In most situations, the use of donor egg IVF has the most dramatic impact on a patient's chance for conception. In many cases a patient may be told there is little to no chance for success without donor egg IVF. With donor egg IVF, clinical pregnancy rates per attempt are 60-70%. It is usually the most successful form of treatment we can offer. Though a miracle for many, it is clearly not the right choice for everyone. There are many issues to consider, as obviously the donor egg recipient and "birth mother" is not the "genetic mother." There are also the issues of disclosure with anonymous egg donation. Do you tell friends, family and the child the identity of the "genetic mother?"

To address this often difficult question, a review article was recently published that closely examined the issue of disclosure in assisted reproduction involving donor sperm or donor egg IVF. This article summarized recent studies that assessed the impact of disclosure on egg or sperm donors, intended parents and offspring. The following represents excerpts of the study findings related to intended parents and offspring in donor egg IVF cycles. The impact of disclosure on egg and sperm donors has not yet become a major issue in the United States. However, in countries such as the United Kingdom where a donor registry is in place and a voluntary exchange and contact registry is proposed, the number of available donors is declining.

Two recent studies have been published examining how donor egg recipients make decisions about disclosure. In the first study, 79 couples undergoing donor egg IVF underwent an in-depth interview regarding how they dealt with disclosure issues. In approximately half of the couples interviewed, there was a difference in opinion regarding whether or not to tell friends, family or the child that the pregnancy was a result of donor egg IVF. Interestingly, by the end of the study, 95% of couples were able to reach a united decision about disclosure. This suggests that it is fairly common for a couple to initially disagree about disclosure in the setting of donor egg IVF. However, using a host of resources including professional counseling, the vast majority of couples reach an agreement. In the second study, in-depth interviews were conducted with women who conceived through the use of donor egg IVF. From these interviews, two main themes were noted. One was described as "engaging in selective disclosure"- patients would decide what information to disclose and to whom. The other theme was described as "responsibility toward the resulting child." For women that disclosed, this meant the right of the child to know. Non-disclosing and undecided women voiced concerns about the negative impact on parental relationships and possible social stigma and did not see a benefit from disclosing to offspring.

Regarding what is best for the child conceived through donor egg IVF, very few studies have adequately addressed this issue. Golombok and colleagues evaluated 48 families with a child conceived through donor egg IVF (also included were children born through donor sperm and naturally conceived children for comparison). They noted that 54% of families with children conceived through donor sperm or donor egg IVF intended to disclose, 46% did not plan to disclose or were undecided. No differences in parent-child relationships were noted between those families that did not disclose and those that did. However, study conclusions were limited as the children were only 2 years old. Subsequent reports from this group have evaluated families and their children at age 4-5 and 12 years old. At an approximate age of 4-½ years old, children conceived through donor egg IVF were not experiencing increased levels of psychological problems. At age 12, a time at which psychological problems might be expected to develop based on the experience of adopted children, donor egg children continued to show no evidence of psychological problems as assessed by direct interview and questionnaires. Interestingly, at the time of the study, only 6 out of the 17 families studied had already told, or planned to tell their child that they were conceived through donor egg.

Though the issue of disclosure can be a difficult one, patients should be comforted in knowing that research to date has not been able to document any adverse affects on the family or the child, regardless of how a patient approaches the issues of disclosure. However, it must be noted that this research is still in the preliminary stages and that hopefully, future studies will provide more definitive data.

This article, with a complete list of references, is available on the library at http://www.givf.com/

Lycopene Good for Sperm and Eggs

By: Amy Erickson Hagen, MS, Cryogenic Laboratories, Inc.

Ever wonder where nature's red comes from? In the case of tomatoes, watermelon, pink grapefruit and guava, it can be attributed to an antioxidant called lycopene. A member of the carotenoid family (same family as Vitamin A but with no Vitamin A activity), lycopene infuses fruits with color and offers several healthful properties most notably for its association with decreased cancer risk. Research now indicates that lycopene supplements and lycopene-rich foods such as tomatoes, carrots, pink grape fruit, tomato sauce, and water melon can have a positive impact on both sperm and eggs.

Because lycopene is thought to be an anti-oxidant, a team of investigators at Montreal’s McGill University examined the antioxidant properties of lycopene on sperm. Oxidative stress can harm sperm, so it was thought washing the sperm with lycopene might protect them. Freshly prepared sperm solutions from proven fertile sperm donors were pre-incubated in solutions with or without lycopene. Sperm were then exposed to hydrogen peroxide , which causes oxidative damage to sperm DNA. The sperm samples that had been pre-treated with the lycopene showed less DNA damage than the samples that had not been treated. The researchers concluded that lycopene can protect sperm DNA from the effects of oxidative stress.

The McGill researchers also reported that oxidative damage is linked to male infertility, as is a low semen lycopene level. A 1996 study appearing in the Archives of Andrology revealed a connection between dietary antioxidants and male fertility and showed reduced seminal lycopene levels in infertile subjects. The good news is that lycopene supplementation may improve seminal lycopene levels, thereby potentially improve semen quality. A study reported in 2002 at the International Urology and Nephrology meetings indicated that after 3 months of lycopene supplementation, participants exhibited significant improvements in sperm concentration, motility and morphology.

For females it is thought that reactive oxygen species, which cause oxidative damage, can play an important role in the development of adhesions. Scientists from Wayne State University treated adhesive tissues with lycopene to see if the expression of proteins associated with adhesions could be reduced . They found that, in fact, treating the tissue with lycopene significantly reduced the levels of those proteins. Further investigation will be needed to whether lycopene treatment has a clinical impact on adhesion reduction.

Although further research is needed to determine the true impact of lycopene on sperm and eggs, the growing body of evidence showing lycopene's benefits support making lycopene-rich foods a part of your diet.

Fertility Clinic Offers Free Cycles

The Genetics & IVF Institute (GIVF) in Fairfax, Virginia (in the Washington, DC suburbs) recently gave a free donor egg IVF cycle to one attendee of an educational seminar held in Bethesda, Maryland. GIVF is planning a series of educational seminars in the Washington DC area and elsewhere. Those interested in notices about these seminars should sign up here.

Study Contradicts the Role of Stress in Fertility Treatment

Women undergoing IVF treatment can now be reassured that their anxiety or depression does not likely affect their IVF success. Infertility is already a stressful situation and many patients worry that stress can ruin their chances at a successful cycle. A recent Danish muticenter study reported in the Journal of Human Reproduction included 421 women on their first IVF cycle. The women were questioned to assess their anxiety and depression symptoms at various points in their cycle. The researchers found that anxiety/depression symptoms were unrelated to the cycle cancellation rate or pregnancy rate. Some studies have linked stress to a lower pregnancy rate, while other studies have showed no correlation. The researchers noted that further large studies are needed to understand the role that stress plays in fertility. While this study can be comforting to women it is important to utilize methods to reduce stress for your overall physical and mental well being.

A Donor Offspring Opinion

An interesting article, written by an adult male who was conceived via donor sperm, outlines the growing problems sperm banks are facing. Governments around the world are passing rules restricting or eliminating anonymity for sperm donors. The results that were predicted by some experts have occurred. Most of the countries that have adopted these rules are suffering shortages of donors and in some countries, prospective parents must endure long waiting lists to get their donor of choice. Others may have to choose another donor because of limited inventory on their donor. The author of the article points out that some donors may not mind being contacted by their offspring years later, however, most donors value the anonymity that is promised to them. Legal decisions by various authorities appear to have overturned contracts signed in good faith years earlier. The author also points out the troubling economics of these policies. Supply and demand dictates that the price of donor sperm will go up when supply runs low (or out). As the supply of donor sperm is severely decreased by these policies, sperm prices for the remaining supply will increase sharply. Also, as the supply of donor sperm decreases, women have less options in terms of selecting the personal and physicial characteristics of a donor they may desire, and may even seek donor sperm through unregulated sources. Fortunately, the restrictions that have sparked the sperm shortages in other countries have not been implemented in the U.S. Let us hope that we can learn from the mistakes in other countries and keep donor sperm available and affordable in the U.S.

Preconception Gender Selection and the Use of Genetic Testing of Embryos

By: Gary L. Harton, BS, TS(ABB)

References to choosing the gender of your baby go back almost as far as written records so it should be no surprise that this topic remains hot today. Eating certain foods, having intercourse at specific times during the female cycle, specific sexual positions have all been touted as assuring the boy or girl you and your partner have always wanted. None of these techniques holds water when couples try and ‘choose’ the gender of a child before conception. On a more scientific note, other methods have been reported to be able to change the ratio of male or female sperm prior to conception by having sperm ‘swim’ a certain way or another, or spinning the sperm in a centrifuge to separate the X-bearing from Y-bearing sperm; however, these techniques only seem to work in the hands of those that promote them and are not reproducible in "outside" laboratories. A fairly new technique, at least new to humans, is currently being investigated that actually seems to do what it says it can do. This technique, called MicroSort, separates the X-bearing (female) from Y-bearing (male) sperm based on the very small difference in DNA content between the two types of sperm. This technique has been shown to skew the ratio of X/Y sperm in actual samples of sperm after the separation, in embryos that have been tested prior to implantation (preimplantation genetic diagnosis-PGD), and in live-born gender ratios. In other words, IT WORKS!

But, what about using the technique? How do Americans feel about the use of the technique? These were questions that a group of researchers at Johns Hopkins University set out to answer. It seems that most people were neutral on the more ‘natural’ methods of gender selection, mainly because they really don’t work. Here we are now with the question of what to do with a technique that actually does seem to work. A study published in 2008 in Human Reproduction looked at this question and the results were interesting. The researchers at Johns Hopkins used focus groups from 5 different US cities and people of various ages, sexes, race/ethnicities, religions, education levels and parental status, and asked participants to think about how they would counsel a friend considering using such techniques. The ‘friend’ was interested in 3 scenarios: 1) gender selection to avoid genetic disease, 2) gender selection for family balancing (choosing the gender least represented in a family), and 3) gender selection for a first-born child. There was almost universal agreement that the use of preconception gender selection (PSS) for the prevention of X-linked diseases was acceptable. There were mixed feelings among focus group participants on the use of PSS for family balancing with the most common complaint being that parents were being selfish by choosing the gender of the child instead of seeing the child as a gift. The use of PSS for a first-born child mainly brought up the concern of gender imbalance in cultures that favor males over females, but most groups dismissed this fear as not applying to US culture. Finally, the groups discussed governmental regulation of techniques for PSS and most groups were not in favor of governmental regulation of any kind.

The study concluded that Americans would probably not have much issue with the use of PSS for the avoidance of genetic disease; however, some Americans would worry about the use of PSS for more personal reasons. Some of the groups assumed that physicians would help patients make the right decision and could operate without the need for regulation from the government or other institutions. The worry about PSS leading to gender imbalance was basically dismissed as not being a problem in most of the Western World. The study concluded that Americans will probably be very accepting of preconception gender selection, even for non-medical purposes, and its use will face little public opposition if it became widely available.

New Findings For Endometriosis

New discoveries in identifying the causes of endometriosis were reported in the January issue of the New England Journal of Medicine. Endometriosis is a chronic disease that affects 5-10 million women in the U.S. It is defined as growth of endometrial tissue outside the uterine cavity. Women with endometriosis generally have pelvic pain or are infertile.

Researchers have been working for the last 10 years to discover the cause of this painful disease. They found the presence of the enzyme aromatase, which produces estrogen, in the diseased tissue. Normal endometrium does not contain aromatase. Consequently women with endometriosis have an excessive amount of estrogen. It was found that the protein SF1 that produces aromatase, which is supposed to be shut down, is active in endometriosis. They also found an abnormality in the progesterone receptor. In patients with endometriosis this receptor is inappropriately turned off. Normally progesterone would act in blocking the growth of endometriosis.

As a result of these findings researchers have launched clinical trials using aromatase inhibitors, which are currently used in breast cancer treatment. The drugs block estrogen formation and secondarily improve progesterone responsiveness. The researchers believe that the abnormalities found are present very early in embryonic development and may be caused by environmental toxins.

Yoga And Fertility

Can yoga help you get pregnant? Probably not, but it can help improve your mental health during a stressful time. According to this article a growing number of yoga studios are now offering classes specifically for infertility patients. Women are turning to yoga to complement traditional Western medical treatments for fertility. Yoga is a Hindu system of philosophy aimed at spiritual, mental, and physical wellbeing by means of deep meditation (dyana), prescribed postures (asanas), and controlled breathing (pranayama). The postures are performed to promote blood flow to the entire body and the breathing and meditation techniques are used to quiet, clarify, and discipline the mind.

Alice Domar, executive director of the Domar Centre for Mind/Body Health recommends yoga to her patients. "There are three reasons why I have my fertility patients do yoga," she says. "One: It's very effective relaxation. Two: Infertility patients tend to be angry with their bodies. They're not doing what they want them to do, and yoga gives them back the sense that their body can make them feel good. And three: I personally believe, and there's some data to support this, infertility patients need to cut down on the intensity and frequency of aerobic exercise, and hatha yoga is a phenomenal substitute." Many patients find another great benefit of the class- meeting other people who are going through the same experience and talking about their common struggles.

LIVE:ON Kit Update

Sperm Banking by Mail to Preserve Fertility for Cancer Patients

By: Amy Erickson Hagen, MS, Cryogenic Laboratories, Inc.

It has been just over one year since the successful launch of the Live:On Kit which was unveiled in a November 13, 2007 article in The Wall Street Journal. The Live:On Kit reduces the barriers facing cancer patients who wish to bank sperm and allows sperm to be preserved through use of this mail-in sperm banking kit. Today more than 1,500 Live:On kits have been sent to over 1,250 oncology professionals throughout the United States to be available in their offices for cancer patients to bank semen. Thanks to the Live:On kit, the time required to find a clinic, distance of sperm banks from a patient’s home or hospital, and feeling awkward about visiting a sperm banking facility at the emotional time of a cancer diagnosis are all eliminated as obstacles to banking sperm.

Why is it important to preserve fertility prior to treatment? Cancer, itself, can cause infertility depending on its type and stage. Often, cancer treatments such as chemotherapy, radiation or surgery might also cause the individual to become infertile. In recent years, sperm banking has become recognized as an effective way to preserve a boy’s or man's fertility before cancer treatment starts. As long as sperm are successfully frozen and stored in proper conditions, they can survive indefinitely. Sperm that has been frozen for over 25 years has been used successfully to achieve pregnancy. The Live:On kit uses proven methods of successfully freezing sperm to preserve an individual’s fertility.

The Live:On kit has been featured in newspaper articles, television reports, radio discussions, and internet postings. These media outlets have allowed over 7 million people to receive the message that sperm banking prior to cancer treatment is of vital importance and that the Live:On kit can facilitate this storage. To support cancer patients who want to preserve their fertility, Cryogenic Laboratories (CLI) entered into a partnership with two non-profit organizations active in this area: the Lance Armstrong Foundation and Fertile Hope. CLI will donate a portion of the sperm banking and storage fees from the use of the kit to the Lance Armstrong Foundation and Fertile Hope.

The Live:On kit can be ordered by oncology professionals free of charge to be readily available to distribute to newly diagnosed patients seeking a sperm banking option. Live:On kits can be ordered by calling 800/466-2796 or visiting www.liveonkit.com.